Supplementary Appendix to manuscript submitted by Trappe, R.U. et al: Response to rituximab induction is a predictive marker in B-cell post-transplant lymphoproliferative disorder and allows successful stratification into rituximab or R- CHOP consolidation in an international, prospective, multicenter phase II trial Supplementary Results Per-protocol analysis In a per-protocol analysis 32 patients who had violated inclusion criteria, had not received any protocol treatment, were lost to follow-up before final staging or deviated from protocol treatment were excluded. Patients who discontinued protocol treatment due to disease progression during R-CHOP treatment or treatmentrelated complications at any time remained in the per-protocol analysis. One patient had died before the start of protocol treatment and two were lost to follow-up before final staging. Violations of inclusion criteria had occurred in twelve patients: six with an ECOG >2, two patients without measurable disease (defined as > 2 cm in diameter and/or bone marrow involvement) and four patients whose diagnosis on pathology review was not CD20-positive PTLD. These were three cases of CD20-negative PTLD (two cases of Hodgkin s PTLD, one of plasmablastic PTLD) and one of HHV-8 associated multicentric Castleman s disease. Deviation from protocol treatment occurred in 17 patients. Three left protocol treatment at interim staging: One patient in CR chose to stop treatment and two patients in PR left the trial protocol and received radiotherapy instead of chemotherapy (physician choice). One patient had unscheduled therapy and moved to R-CHOP early despite no evidence of progression under rituximab induction. Finally, 13 patients received unscheduled additional chemo- or radiotherapy consolidation after completion of protocol treatment (rituximab induction and R-CHOP, none had achieved a complete remission with rituximab induction): eleven patients received chemotherapy (ten in partial remission, one with stable disease) and two patients received radiotherapy (one in CR, one in PR). The results in the per-protocol cohort (120 patients) confirmed the results of the intention-to-treat analysis: ORR of RSST was 87% (90/103; CR: 77% [79/103]). Median DR and median TTP were not reached; the 3-year Kaplan-Meier estimates were 85% (95% CI 77 94) and 77% (95% CI 68 85). Median OS was 7 1 years with a 3-year Kaplan-Meier estimate of 74% (95% CI 66 83). Multivariable analysis of prognostic factors We have previously reported overall response to rituximab (CR/PR vs. SD/PD), baseline international prognostic index (IPI, 3 vs. <3) as well as the transplanted organ (thoracic vs. other) as significant prognostic factors for overall survival in PTLD-1 ST. 1 To identify the prognostically relevant baseline components of different PTLD scoring systems including the IPI we had performed univariate analyses for ECOG performance status, age, Ann Arbor stage, LDH, presence of extranodal disease, graft involvement, monomorphic disease, the transplanted organ (thoracic versus other) and response to rituximab. Only ECOG performance status, age, response to rituximab and thoracic organ transplant correlated with OS. Only ECOG >2 and response to rituximab correlated with TTP. In total three parameters remained significant for OS in the PTLD-1 ST trial cohort in multivariable analysis: age >60, thoracic organ transplant and overall response to rituximab when analysed in combination with the parameters of our previously published multivariable Cox regression analyses of factors affecting OS and TTP (age, sex, time-to-ptld, EBV association, advanced stage, extranodal disease, serum LDH, ECOG 2 and violation of exclusion criteria). 2 For TTP, two parameters remained significant: overall response to rituximab and thoracic organ transplant. To validate the factors thoracic organ transplant, overall response to rituximab and IPI 3 in an independent 1
Trappe et al. patient cohort, we performed a backward-step log-rank multivariable Cox regression analysis including the factors thoracic organ transplant, overall response to rituximab and IPI 3 in the current trial cohort. This demonstrated that overall response to rituximab induction and baseline IPI 3 are highly significant independent prognostic factors for both OS and TTP in the 140/152 patients with available IPI and rituximab response data (Supplementary Table 2). High-risk group and comparison with PTLD-1 sequential treatment In the 111 patients allocated to R-CHOP consolidation, ORR was 78/92 (85%) with 55/92 (60%) complete remissions compared to 89% and 60% in the 56 patients in the PTLD-1 ST cohort not in CR after rituximab induction. Median TTP (Supplementary Figure S4A) was not reached. The 3-year Kaplan-Meier estimate was 70% (95% CI 61 80) compared to 69% (95% CI 56 82) in PTLD-1 ST. Median OS (Supplementary Figure S4B) was 7 1 years (95% CI 3 7 10 4) with a 3-year estimate of 64% (95% CI 55 74) compared to 5 1 years (95% CI 2 0 8 2) and 55% (95% CI 41 68) in PTLD-1 ST. Trial protocol http://www.lymphome.de/gruppen/dptldsg/protokolle/ptld-i-3amendment/ptld-1-3.pdf References quoted in the supplementary appendix: 1 Trappe RU, Choquet S, Dierickx D, et al. International Prognostic Index, Type of Transplant and Response to Rituximab Are Key Parameters to Tailor Treatment in Adults With CD20-Positive B Cell PTLD: Clues From the PTLD-1 Trial. Am J Transplant 2015; 15: 1091 100. 2. Trappe R, Oertel S, Leblond V, Mollee P, Sender M, Reinke P, et al. Sequential treatment with rituximab followed by CHOP chemotherapy in adult B-cell post-transplant lymphoproliferative disorder (PTLD): the prospective international multicentre phase 2 PTLD-1 trial. Lancet Oncol. 2012; 13(2):196 206.
Supplementary Table 1: Comparison of baseline patient characteristics in the low-risk (patients in CR after rituximab induction) and high-risk (patients not in CR after rituximab induction) cohorts. Low-risk (n=37) High-risk (n=111) p Age/years: median (range) 48 5 (20 70) 58 0 (18 82) 0 071 60 years 10/37 (27%) 47/111 (42%) 0 097 Male 29/37 (78%) 83/111 (75%) 0 658 Transplant type Kidney 21/37 (57%) 45/111 (41%) Liver 6/37 (16%) 33/111 (30%) Lung 6/37 (16%) 12/111 (11%) Heart 2/37 (5%) 13/111 (12%) 0 316 Heart + kidney 1/37 (3%) 4/111 (4%) Kidney + pancreas 0 3/111 (3%) Heart + lung 1/37 (3%) 1/111 (1%) Time from transplantation to PTLD/years: median (range) 1 5 (0 2 27 9) 10 0 (0 18 26 1) 0 008 < 1 year 16/37 (43%) 16/111 (14%), 1 year 21/37 (57%) 95/111 (86%) <0 001 Histology Early lesion 0 2/111 (2%) Polymorphic 6/37 (16%) 14/111 (13%) Monomorphic 31/37 (84%) 94/111 (85%) Burkitt 1/37 (3%) 5/111 (5%) DLBCL 27/37 (73%) 82/111 (74%) Other B-cell, CD20-positive 3/37 (8%) 4/111 (4%) Other B-cell, CD20-negative 0 3/111 (3%) Multicentric Castleman s disease 0 1/111 (1%) EBV-association EBV-associated 23/36 (64%) 42/104 (40%) Non-EBV-associated 13/36 (36%) 62/104 (60%) 0 015 Ann Arbor stage* I 11/37 (30%) 18/110 (16%) II 5/37 (14%) 15/110 (14%) III 2/37 (5%) 18/110 (16%) 0 139* IV 19/37 (51%) 59/110 (54%) LDH Within normal range 13/37 (35%) 39/109 (36%) Elevated 24/37 (65%) 70/109 (64%) 0 944 Nodal disease 23/37 (62%) 85/110 (77%) 0 072 Extranodal disease 26/37 (70%) 80/110 (73%) 0 773 Gastrointestinal 8/37 (22%) 34/110 (31%) Liver 10/37 (27%) 24/110 (22%) Lung 7/37 (19%) 19/110 (17%) Kidney 1/37 (3%) 3/110 (3%) Bone marrow 2/37 (5%) 10/110 (9%) International Prognostic Index (IPI) <3 26/34 (76%) 60/106 (57%) 3 8/34 (24%) 46/106 (43%) 0 038 ECOG performance status 0 17/34 (50%) 22/107 (21%) 1 12/34 (41%) 53/107 (50%) 2 4/34 (12%) 27/107 (25%) 0 663 3 1/34 (3%) 5/107 (5%) DLBCL: diffuse large B-cell lymphoma, EBV: Epstein-Barr Virus, ECOG: Eastern Cooperative Oncology Group. *Stages I and II (localized) and III and IV (disseminated) combined for comparison. Levels 0-2 and 3-4 combined for comparison. 3
Trappe et al. Supplementary Table 2: Multivariable Cox-regression analyses for OS and TTP. Factors included in these analyses were: Thoracic organ transplant (heart, lung or combination involving heart or lung), overall response to rituximab (CR/PR vs. SD/PD) and baseline IPI 3. Cox regression model n=140, Step 2, p<0 001 OS Risk factor p HR 95% CI IPI 3 0 001 2 540 1 461 4 418 Response to rituximab <0 001 0 320 0 180 0 571 Cox regression model n=140, Step 2, p<0 001 TTP Risk factor p HR 95% CI IPI 3 0 001 3 338 1 624 6 862 Response to rituximab <0 001 0 256 0 119 0 549 OS indicates overall survival, TTP time to progression, HR hazard ratio, and CI confidence interval. Thoracic organ transplant was excluded from the model (p=0 474 for TTP and p=0 137 for OS).
Supplementary Table 3: Comparison of baseline characteristics: Patients treated in the PTLD-1 trial with sequential treatment (n=70) 2 and risk-stratified sequential treatment (n=152). PTLD-1, sequential treatment (n=70) 2 PTLD-1, risk-stratified sequential treatment (n=152) Age/years: median (range) 53 3 (16 74) 56 4 (18 82) 0 062 60 years 21/70 (30%) 60/152 (40%) 0 173 Male 47/70 (67%) 115/152 (76%) 0 184 Transplant type Kidney 29/70 (41%) 69/152 (45%) Liver 16/70 (23%) 40/152 (26%) Heart 14/70 (20%) 15/152 (10%) Lung 4/70 (6%) 18/152 (12%) Heart + kidney 0 5/152 (3%) Kidney + pancreas 4/70 (6%) 3/152 (2%) Heart + lung 2/70 (3%) 2/152 (1%) Bone marrow 1/70 (1%) 0 Time from transplantation to PTLD/years: median (range) 5 5 (0 1 25 3) 9 0 (0 2 27 9) 0 019 < 1 year 17/70 (24%) 32/152 (21%) 1 year 53/70 (76%) 120/152 (79%) 0 589 Histology Early lesion 0 2/152 (1%) Polymorphic 3/70 (4%) 20/152 (15%) Monomorphic 67/70 (96%) 129/152 (85%) Burkitt 2/70 (3%) 6/152 (4%) DLBCL 57/70 (81%) 112/152 (74%) Other B-cell, CD20 positive 6/70 (9%) 8/152 (5%) Other B-cell, CD20 negative 2/70 (3%) 3/152 (2%) Multicentric Castleman s disease 0 1/152 (1%) EBV-association EBV-associated 29/66 (44%) 67/144 (47%) Non-EBV-associated 37/66 (56%) 77/144 (53%) 0 727 Ann Arbor stage* I 9/70 (13%) 30/151 (20%) II 9/70 (13%) 20/151 (13%) III 10/70 (14%) 22/151 (15%) 0 268* IV 42/70 (60%) 79/151 (52%) LDH Within normal range 17/68 (25%) 53/150 (35%) Elevated 51/68 (75%) 97/150 (65%) 0 130 Nodal disease 40/57 (70%) 110/151 (73%) 0 701 Extranodal disease 54/67 (81%) 108/151 (72%) 0 157 Gastrointestinal 17/64 (27%) 43/151 (28%) Liver 12/64 (19%) 34/151 (23%) Lung 10/64 (16%) 26/151 (17%) Kidney 3/64 (5%) 4/151 (3%) Bone marrow 7/64 (11%) 12/151 (8%) International Prognostic Index (IPI) <3 36/65 (55%) 88/143 (62%) 3 29/65 (45%) 55/143 (38%) 0 402 ECOG performance status 0 31/68 (46%) 40/144 (28%) 1 18/68 (26%) 66/144 (46%) 2 13/68 (19%) 32/144 (22%) 0 171 3 5/68 (7%) 6/144 (4%) 4 1/68 (1%) 0 DLBCL: diffuse large B-cell lymphoma, EBV: Epstein-Barr Virus, ECOG: Eastern Cooperative Oncology Group. *Stages I and II (localized) and III and IV (disseminated) combined for comparison. Levels 0-2 and 3-4 combined for comparison. p 5
Trappe et al. Figure S1: Time to progression and overall survival by response to rituximab induction (blue: CR, orange: PR, violet: SD, green: PD, n=148). Numbers at risk for each population are indicated at the bottom of each graph. A: Time to progression (p<0.001). B: Overall survival (p<0.001). Of the six late deaths that occurred in patients in CR, two were attributable to progressive PTLD (after first and second relapse, respectively) whereas four were not: one death form unknown causes and three from infections.
Figure S2: Time to progression and overall survival by international prognostic Index <3 (n=88, solid line) and 3 (n=55, dashed line). 143 patients are included, as IPI data was missing in 9 patients. A: Time to progression (p=0.001). B: Overall survival (p=0.001). 7
Trappe et al. Figure S3: Time to progression and overall survival by EBV-association of PTLD. EBV-positive PTLD (n=67, solid line); EBV-negative PTLD (n=77, dashed line), EBV-status missing in 8 cases. Numbers at risk for both populations (EBV-positive and EBV-negative) are indicated at the bottom of each graph. A: Time to progression (p=0.908). B: Overall survival (p=0.793).
Figure S4: Time to progression and overall survival in the 111 patients allocated to R-CHOP consolidation (high-risk group, n=111, solid line) in comparison to the 56 patients in the PTLD-1 ST cohort 2 not in CR after rituximab induction (n=56, dashed line). Numbers at risk for both populations (RSST and ST) are indicated at the bottom of each graph. A: Time to progression. The 3-year Kaplan-Meier estimate was 70% (95% CI 61 80) compared to 69% (95% CI 56 82) in PTLD-1 ST (p=0 759). B: Overall survival. Median OS was 7 1 years (95% CI 3 7 10 4) with a 3-year estimate of 64% (95% CI 55 74) compared to 5 1 years (95% CI 2 0 8 2) and 55% (95% CI 41 68) in PTLD-1 ST (p=0 304). 9